Ignite your Lent Saturday, February 21st

Student's name *

Date of Birth *+

Gender *

Grade *

Parent/Guardian Name *

Relationship to child *

Street Address *

City *

State *

Zip Code *

Mom's phone # *

Dad's Number *

Email Address *

I grant permission for the student listed above to participate in the above named activity and I warrant that my child is in good health. In consideration of my child’s participation, I agree to hold Divine Mercy Catholic Church and the Archdiocese of St. Paul & Minneapolis harmless from any and all claims resulting in my child’s participation in this event. I further agree to indemnify Divine Mercy Catholic Church and the Archdiocese of St. Paul & Minneapolis from any claims or law suits brought against Divine Mercy Catholic Church and the Archdiocese of St. Paul & Minneapolis by myself, my child or others, that arises out of any behavior by my child at the event/activity described above and for any harm my child incurs by reason of their participation in the above described event. I also agree to pay reasonable attorney’s fees or expenses incurred by Divine Mercy Catholic Church and the Archdiocese of St. Paul & Minneapolis.

USE OF IMAGE: I grant permission to Divine Mercy Catholic Church and the Archdiocese of St. Paul & Minneapolis to use and publish for advertising, commercial or publicity purposes, likeness of my child, or for any other lawful purposes whatsoever, including photographic portraits, pictures, reproductions, made through any medium, including electronic media, and the undersigned parent/guardian does hereby release Divine Mercy Catholic Church and the Archdiocese of St. Paul & Minneapolis or anyone authorized by the with such use. This authorization and consent permits such use to associate my child’s name with the likeness for such purposes provided such use is consistent with the acceptable use policy for electronic communications and other policies.

EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I give permission to transport my child to a hospital for medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital. In the event of any emergency, if you are unable to reach me at the above numbers please use the contact information below.

Emergency Contact/Relationship to Student *

Phone Number *

Emergency Contact/Relationship to Student *

Phone Number *

Medical Information

Family Doctor, Clinic & Phone number *

Health Insurance Information *

Medication my child is taking at present: *

Allergies or other health concerns we should be aware of: *

Do you allow your child to participate? *

Yes, I give permission

No, I do not give permission

Signature *

clear

Code of Conduct

Please remember you are representatives of Divine Mercy Catholic Church. We expect you will represent your parish, school and the Archdiocese well during this event. Recall that you are a witness to Christ to the press and others who will attend this gathering. We ask you to project an image of Christian charity and respect to everyone and to the property around you. We are confident you will display maturity, responsibility in leadership and character.

Thank you!

Participants are responsible for their actions. Each participant accepts the full responsibility for any damage or theft caused while attending this event. Leaders/Chaperones are expected to enforce the Code of Conduct and set an example for the participants.

1. I will not use my cell phone except for photos and during explicitly appointed times. I will immediately give my phone up if a chaperone asks for it.2. I will treat all persons as a son or daughter of God with dignity and respect. I will not intentionally cause any harm (physically, emotionally, or spiritually) to any person in any way.3. I will respect the property of others, including all program facilities.4. I will follow all appropriate instructions of all personnel aiding in this event, including, but not limited to, chaperones, support staff, transportation personnel and administration.5. I will be on time for all check-ins and departure times.6. I will attend all activities and remain with their group or designated subgroup at all times. I will wear my lanyard at all times with the appropriate documentation and medical release forms.7. I will not purchase, possess or use alcohol or illegal drugs. If you have prescription medication, your group leader and Archdiocesan staff must be informed before the trip.8. I will not purchase, possess or use any tobacco products, including e-cigarettes of any kind9. I will not purchase, possess or view sexually explicit or morally inappropriate materials in any form.10. I will not purchase or possess any weapons. Possession of a weapon will mean immediate dismissal.11. I will be aware of noise levels in sleeping areas. I will respect others’ need for sleep, quiet time and privacy.12. I will dress modestly at all times.